079200823-7-8-2025-15-AS-HHUL-DK2NN5-20250729103610

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200823
Report Date: 07/08/2025
Date Signed: 07/08/2025 12:58:04 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/01/2024 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240701091410

FACILITY NAME:	J & M RESIDENTIAL CARE II		FACILITY NUMBER:	079200823
ADMINISTRATOR:	MARIA A GIL		FACILITY TYPE:	735
ADDRESS:	2933 EL PASO WAY		TELEPHONE:	(925) 978-4890
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	6	CENSUS: 6	DATE:	07/08/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Daniela Dominguez Reyes, Direct Support Staff		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Resident sustained unexplained injuries

INVESTIGATION FINDINGS:

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On 7/8/2025, at 12:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Daniela Domingues Reyes, Direct Support Staff. Administrator Olivia Gonzalez, arrived at 12:53pm, and explained the purpose of the visit.

The Department’s investigation included but was not limited to interviews with current and former staff, witnesses, and residents. The Department also collected records, including medical records from Kaiser Permanente Hospital and a copy of the Adult Protective Services report (APS). Incident reports and employee roster were also reviewed and copies obtained.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240701091410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: J & M RESIDENTIAL CARE II	FACILITY NUMBER: 079200823
	VISIT DATE: 07/08/2025

NARRATIVE

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Continued from LIC9099.

The Department concluded a complaint investigation and unsubstantiated the following allegation: Resident sustained unexplained injuries.

Based on the investigation, it was revealed that C1 was taken to Kaiser Permanente Hospital Antioch Emergency Department (ED) on July 6, 2024, due to bruising on his private part. Facility staff did not know how C1 sustained the injury. Review of C1’s medical records received from Kaiser Permanente on May 21, 2025, indicated W4 spoke with C1’s responsible party and S1 and reported that C1 has had previous episodes of agitation, punching and hurting himself and that C1’s injury was possibly self-inflicted.

The Department interviewed W1 on August 27, 2024, who confirmed that C1 has a history of self injurious behaviors including injuries to his private part. During staff interviews, S1, S2, S3, and S4 corroborated W1’s statement that C1 has self injurious behavior where he hits himself hard including his private part. Staff stated that they redirect C1, so he does not hurt himself. Staff indicated that all the other residents at the facility would not hurt C1 due to their limited functioning abilities. Staff denied hurting or causing the injury. The Department interviewed W2 on April 28, 2025. W2 stated an investigation that was also conducted by Adult Protective Services (APS), and based on information gathered, APS finding was unfounded.

Based on the interviews and record review, there is not enough evidence to conclude that C1’s unexplained injury was due to staff neglect or abuse.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

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